Student Support Team Referral Form
Student Support Team Referral Form
For more information regarding the Student Support Team Referral Form, frequently asked questions, or other concerns, please visit:
Student Support Team
Referral Source
Your Name
First
Last
Your Role
Student
Faculty
Staff
Macaulay Advisor
Macaulay Director
Parent
Your Campus
*
Your Campus
Baruch
Brooklyn
City
Hunter
John Jay
Lehman
Queens
College of Staten Island
Macaulay Central
Your Phone
Your Email
Information on student you would like to support
Name of student about whom you are concerned
*
If you do not know the name of the student, please use this space to describe them to the best of your ability. If you are concerned for your own well-being you can still file for yourself, as well.
Incident Information
Location of Incident
Date of Incident
MM slash DD slash YYYY
Please provide a detailed description of the incident(s) or concern using objective language.
*
Any additional information you wish to provide:
Please upload documents, emails or other types of communication relevant to the report
Drop files here or
Select files
Accepted file types: jpg, png, pdf, docx, Max. file size: 5 MB, Max. files: 5.
Allowed file extensions: jpg, png, pdf, docx | Maximum Number of Files: 5
Level of urgency
*
Level of urgency
Emergency
High Priority
Medium Priority
Low Priority
If this is an emergency or life-threatening, please call 911 before submitting this form.
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